Mental Practice in Chronic Stroke

Results of a Randomized, Placebo-Controlled Trial

Stephen J. Page, PhD; Peter Levine, BA, PTA; Anthony Leonard, PhD

Background and Purpose—Mental practice (MP) of a particular motor skill has repeatedly been shown to activate the
same musculature and neural areas as physical practice of the skill. Pilot study results suggest that a rehabilitation
program incorporating MP of valued motor skills in chronic stroke patients provides sufficient repetitive practice to
increase affected arm use and function. This Phase 2 study compared efficacy of a rehabilitation program
incorporating MP of specific arm movements to a placebo condition using randomized controlled methods and an
appropriate sample size.
Method—Thirty-two chronic stroke patients (mean⫽3.6 years) with moderate motor deficits received 30-minute therapy
sessions occurring 2 days/week for 6 weeks, and emphasizing activities of daily living. Subjects randomly assigned
to the experimental condition also received 30-minute MP sessions provided directly after therapy requiring daily MP of
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the activities of daily living; subjects assigned to the control group received the same amount of therapist interaction
as the experimental group, and a sham intervention directly after therapy, consisting of relaxation. Outcomes were
evaluated by a blinded rater using the Action Research Arm test and the upper extremity section of the Fugl-Meyer
Assessment.
Results—No pre-existing group differences were found on any demographic variable or movement scale. Subjects
receiving MP showed significant reductions in affected arm impairment and significant increases in daily arm function
(both at the P⬍0.0001 level). Only patients in the group receiving MP exhibited new ability to perform valued activities.
Conclusions—The results support the efficacy of programs incorporating mental practice for rehabilitating affected arm
motor function in patients with chronic stroke. These changes are clinically significant. (Stroke. 2007;38:1293-1297.)
Key Words: hemiparesis 䡲 occupational therapy 䡲 randomized controlled trials 䡲 rehabilitation 䡲 stroke recovery

A lthough hemiparesis is one of the most pervasive and

disabling impairments,1 evidence supporting stroke re-
habilitation efficacy is limited,2,3 with 30% to 60% of patients
unable to use their more affected arms functionally after
discharge.4 As such, improved rehabilitation strategies are
needed, particularly in the chronic (⬎1 year poststroke) stage,
where spontaneous recovery is often slowed or stopped,5,6
and patients are discharged from rehabilitation.
Mental practice (MP), sometimes called “motor imagery,”
is a technique by which physical skills can be cognitively
rehearsed in a safe, repetitive manner. MP increases motor-
skill learning and performance in rehabilitative settings,7–9
and the same neural and muscular structures are activated
when movements are mentally practiced as during physical
practice of the same skills.10 –14 Other similarities between
MP and physical practice include: (1) the time taken to
mentally and physically perform movements is highly simi-
lar15; (2) during MP, the speed accuracy tradeoff (ie, Fitts
Law) is maintained16; and (3) MP produces similar autonomic
events as physical practice of the same skills.17
Pilot data suggest that the addition of MP to motor therapy
yields greater motor outcomes than conventional motor ther-
apy in subacute18,19 and chronic stroke.20 –23 The needed next
step in this line of research was to perform a randomized
controlled study. This randomized, controlled study com-
pared the efficacy of 2 motor rehabilitation regimens: (1) a
program in which 5 specific arm motor skills were physically
practiced and subjects then listened to a 30-minute tape of
relaxation exercises (relaxation plus physical practice
[R⫹PP]); and (2) a program in which 5 specific arm motor
skills were both mentally and physically practiced (MP⫹PP).
Based on previous study results, our primary hypothesis was
that subjects receiving MP would exhibit significantly greater
fine motor function changes, as shown by the Action Re-
search Arm Test (ARA), a measure of distal motor function,
than subjects in other groups. We also hypothesized that

Received and accepted November 15, 2006.

From the Department of Physical Medicine and Rehabilitation, the Greater Cincinnati/Northern Kentucky Stroke Team (GCNKST), The Institute for
the Study of Health, the Department of Rehabilitation Sciences, and the Neurosciences Graduate Program, all a part of the University of Cincinnati
College of Medicine (UCCOM) (S.J.P.), Ohio; the Neuromotor Recovery and Rehabilitation Laboratory (NMRRL) at Drake Rehabilitation Center
(S.J.P.), Cincinnati, Ohio; UCCOM and NMRRL (P.L.); and the Institute for the Study of Health (A.L.), UCCOM, Ohio.
Correspondence to Stephen J. Page, PhD, University of Cincinnati Academic Medical Center, 3202 Eden Ave, Suite 275, Cincinnati, OH 45267-0530.
E-mail Stephen.Page@uc.edu
© 2007 American Heart Association, Inc.
Stroke is available at http://www.strokeaha.org DOI: 10.1161/01.STR.0000260205.67348.2b

1293
 1294 Stroke April 2007
MP⫹PP subjects would exhibit markedly larger score in-
creases on the Fugl-Meyer Impairment Scale. Given the
previously stated need for improved rehabilitation strategies,
this study was part of a larger program to develop clinically
practical, efficacious strategies to improve motor function
after stroke.
Subjects and Methods
Power Analysis and Subjects
Based on previous MP studies, our primary outcome measure was
the ARA (described later), and our main hypothesis was that subjects
receiving the MP⫹PP intervention would exhibit the greatest in-
creases in scores on the ARA. To reach 80% power (and effect size
of 0.36, considered medium-high) using a F test to test the group by
time interaction at a 5% significance level, 15 subjects were found to
be needed in each group for a total number of 30. A power analysis
was also conducted using Sample Power ANOVA model, in which
anticipated means for the 2 conditions were entered into the model,
as well as average between and within groups variances. Based on
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aforementioned pilot data, we set the effect size for the interactions
to be high (f⫽0.40). Results were similar to those obtained in the
initial power analysis; whereas 80% is the “standard” for power
analyses, because the MP effect was high in initial studies, to obtain
only 69% power (0.40 effect size) at a 5% significance level, 15
patients were needed/group for a total number of 30.
Volunteers were recruited using advertisements placed in neurol-
ogy and physical therapy clinics in hospitals in the Midwestern
United States. A research team member screened volunteers using
the following inclusion criteria from previous MP research: (1)
history of no more than one stroke; (2) ability to actively flex at least
10° from neutral at the affected wrist and the metacarpophalangeal
and interphalangeal joints of two digits; (3) stroke experienced ⬎12
months before study enrollment; (4) a score ⱖ69 on the modified
Mini Mental Status Examination24; (5) age ⬎18 and ⬍80 years. We
also applied the following exclusion criteria: (1) excessive spasticity,
defined as a score of ⱖ3 on the Modified Ashworth Spasticity
Scale25; (2) excessive pain in the affected upper limb, as measured by
a score of ⱖ4 on a 10-point visual analog scale; (3) still enrolled in
any form of physical rehabilitation; (4) participating in any experi-
mental rehabilitation or drug studies.
Using the above inclusion/exclusion criteria, a total of 50 volun-
teers were screened, with 18 subjects excluded for the following
reasons: (1) still enrolled in some form of motor rehabilitation
(n⫽2); insufficient motor function in the more affected arm (n⫽8);
(3) excessive spasticity (n⫽5); (4) other medical comorbidities
(n⫽1); (5) too much motor function in the more affected arm
(n⫽2). Thus, 32 patients were found eligible and agreed to
participate (18 males, 14 females; mean age⫽59.5⫾13.4 years,
age range 27 to 81 years; mean time since stroke onset⫽42.0
months, range of onset⫽12 to 174 months; 19 subjects with right
hemiparesis).
Outcome Measures
Instruments used for this study were applied in previous MP studies
by Page and colleagues,18 –21 and were: (1) our primary outcome
measure was the 66-point, upper extremity section of the Fugl-
Meyer Assessment of Motor Recovery After Stroke (FM)26 which
assesses several impairment dimensions using a 3-point ordinal
scale (0⫽cannot perform; 1⫽can perform partially; 2⫽can per-
form fully). The FM has been shown to have impressive test-
retest reliability (total⫽0.98 – 0.99; subtests⫽0.87 to 1.00), interrater
reliability, and construct validity.27–29 The FM has been used
extensively in studies measuring functional recovery in stroke
patients, and is highly recommended for “use in clinical trials
designed to evaluate changes in motor impairment following
stroke.”30; (2) The ARA,31 our primary outcome measure, is a
19-item test divided into 4 categories (grasp, grip, pinch, and gross
movement), with each item graded on a 4-point ordinal scale
(0⫽can perform no part of the test; 1⫽performs test partially;
2⫽completes test but takes abnormally long time or has great
difficulty; 3⫽performs test normally) for a total possible score of
57. The test is hierarchical in that if the patient is able to perform the
most difficult skill in each category, they will be able to perform the
other items within the category and, thus, they need not be tested.
The ARA has high intrarater (r⫽0.99) and retest (r⫽0.98) reliability
and validity.29,32
In addition to their strong psychometric characteristics, both the
FM and ARA are responsive to motor changes in chronic stroke,33
making them ideal outcome measures for this study.
Testing and Intervention
A single-blinded, multiple baseline, randomized, pre- and post-test
control group design was applied. After screening and signing
consent forms approved by the local institutional review board, the
FM and ARA were administered on 2 occasions one week apart. This
multiple baseline design had 2 purposes: (1) it was probable that
chronic stroke patients would exhibit stable motor deficits. However,
given recent findings of improvement years after stroke, multiple
administrations of the outcome measures helped us assure that
individuals were exhibiting stable motor deficits; (2) our repeated
pretesting design increases the stability of the individual motor
estimates, thereby lessening error variance. This will diminish the
effect of any pre-existing individual differences.
After the second pretesting session, patients were randomly
assigned to one of the below described conditions with equal
probability using a computer-generated random numbers table.
Therapists hired for this grant (n⫽5) underwent extensive inservic-
ing so that therapy was consistent from subject to subject. This
included substantial group review of pertinent stroke and MP
literature, hours of cross-validation and videotaping of therapists’
provision of the activities that patients practiced, and information
sessions run by the research team.
Relaxation Plus Physical Practice (RⴙPP)
All subjects practiced activities of daily living during therapy
sessions. These sessions occurred on 2 days per week, in 30-minute
segments, for 6 weeks. All therapy was administered by the same
inserviced therapists in the same fashion and environment. Emphasis
was on bimanually performing activities of daily living listed in
Table 1 through the entire range of motion and, if necessary, the
affected arm supported the less affected hand. This therapy program
was consistent with the methods of previous MP work in which
positive treatment effects were shown.18 –21
Therapists maintained a treatment card for each patient that
detailed the sessions so that researchers could monitor compli-
ance with the protocol. Therapists were blinded to group assign-
ment. Random grouping of patients will minimize effects of
participant characteristics and be useful in distributing participant
characteristics between groups in an unbiased way. All subjects
were instructed to not perform additional PP of any of the skills
at home.
Directly following each therapy session, each subject randomly
assigned to the R⫹PP group listened to a 30-minute tape in which
they were taken through a progressive relaxation program. This
regimen asked subjects to flex different muscles in the body, and
then relax them. Because the MP⫹PP subjects also listened to a tape
with comparable length and frequency (as described below), provi-
sion of the relaxation sequence allowed contact time between the 2
TABLE 1. Sequences on Each Tape, and Where/When Tape
Was Used
Tape No. Functional Task Described Where/When Administered
1 Reaching for and grasping a cup Research lab/Weeks 1, 2
or object
2 Turning a page in a book Research lab/Weeks 3, 4
3 Proper use of a writing utensil Research lab/Weeks 5, 6
 Page et al Mental Practice in Chronic Stroke 1295

TABLE 2. Preintervention Demographics and Scores, By Group impairments (9 subjects wore glasses; 4 wore contact lenses)
MP Mean (SD) PP Mean (SD) 2-tailed P
or sensory impairments. Group differences on dichotomous
variables were tested with Fisher exact test, whereas the other
Age 58.69 (12.89) 60.38 (14.17) 0.72
variables were compared using the Wilcoxon rank sum test.
Months poststroke 38.81 (25.86) 45.19 (0.43.56) 0.85 (These latter variables tended to be distributed in markedly
Mean FM score 33.03 (0.8.37) 35.75 (0.9.51) 0.43 non-normal fashion.) The groups did not differ significantly
Mean ARA score 18.00 (10.99) 17.25 (14.29) 0.70 on any of the interval level baseline measures, which were
Note: 2-sided P denotes 2-sided probability value for Wilcoxon nonparamet- age, time poststroke, FM score, and ARA score (Table 2).
ric test. FM and ARA mean scores are means of 2 testings per subject, with SDs Groups also did not differ on nominal variables before
taken on those mean scores across subjects. n⫽16 per group. intervention. Seven of 16 patients in the MP⫹PP group
exhibited left-side hemiparesis, as did 6 in the R⫹PP group
groups to remain consistent. R⫹PP subjects were instructed not to (exact P⫽1.00). Three other nominal variables, sex (exact
engage in additional relaxation practice at home. P⫽0.29), type of stroke (ischemic versus hemorrhagic; exact
P⫽0.66), and lesion site (cortical, subcortical, or mixed;
Mental Practice (MPⴙPP) exact P⫽0.75), also did not differ between groups at
Subjects randomly assigned to the mental practice plus physical
practice (MP⫹PP) condition participated in the same physical pretesting.
practice regimen, practicing the same activities of daily living in the The primary hypothesis, that scores in the MP⫹PP group
same environment and with the same therapists as individuals in the would show greater changes between pre- and post-treatment
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R⫹PP group. However, in addition to participating in the PP
regimen, the MP⫹PP group mentally practiced the activities per-
formed in therapy, as described in Table 1 and administered in
previous studies.18 –21 Specifically, after each PP session, MP⫹PP
subjects received a recorded MP intervention lasting 30 minutes. As
with previous MP interventions, the MP was read by a male
psychologist, and opened with 5 minutes of relaxation, asking
patients to imagine themselves in a warm, relaxing place (eg, a
beach) and asking them to contract and relax their muscles (ie,
progressive relaxation). This portion of the tape was followed by
suggestions for internal, cognitive polysensory images34 in which the
subjects mentally rehearsed the motor skill that was practiced during
PP earlier that day. For example, when mentally practicing reaching
for a cup, the recording first described the setting in which the patient
was seated (eg, kitchen or therapy gym). The subject was then taken
through the visual image of reaching for the cup from a 1st-person
perspective, as well as the sensations associated with reaching for it
(eg, the feeling of extending the elbow and fingers; the feeling of the
cup in their hand). Several trials of each task were mentally
practiced, so that this middle portion of the tape lasted ⬇20 minutes.
The final minutes of the tape allowed patients to refocus into the
room. MP⫹PP subjects were instructed not to engage in additional
mental practice at home.
Post-Testing
One week after therapy completion, each subject returned to the
laboratory at which pretesting occurred, and the ARA and FM were
again administered by the same examiner who administered pretests.
The examiner was blinded in that he was unaware of subjects’
group assignments.
Results
The 2 groups were compared on demographic variables and
baseline scores. No subjects exhibited stroke-induced visual
ARA administrations than would scores of the R⫹PP group,
was tested using the change scores (time 2 minus the mean of
the 2 baseline testings). The change scores in the 2 groups
were compared using the Wilcoxon rank sum test with exact
probability value computation, attributable to assumed, non-
normal distributions. Pre-, post-, and change-group means
are reported in Table 3. On the ARA the MP⫹PP group
improved an average of 7.81 points, whereas the control
group improved on average only 0.44 points (P⬍0.0001).
On the FM, the MP⫹PP group improved a mean ⫹6.72
points, as compared with 1.0 point changes for the R⫹PP
control group (P⫽0.0001). All subjects and their caregiv-
ers reported not engaging in any additional MP, R, or PP
while at their homes.
Discussion
Hemiparesis is a disabling, common impairment. Given a
paucity of effective, home-based protocols and increased
stroke incidence, interventions are needed that reduce hemi-
paresis and provide opportunities for practice of valued
activities. Previous pilot study results suggest that addition of
mental practice to affected arm rehabilitation increases out-
comes. Using an appropriate sample size and randomized
controlled methods, this phase 2 study compared efficacy of
adding mental practice versus a “sham” program of relaxation
to affected arm rehabilitation.
As in previous studies,18 –21 subjects participating in a
regimen combining MP⫹PP showed large reductions in
affected arm impairment as measured by the FM, and large

TABLE 3. Patient Scores on the FM and ARA Before and After Intervention
FM ARA

PRE Mean POST Mean Change Mean PRE Mean POST Mean Change Mean
(SD) (SD) (SD) (SD) (SD) (SD)
MP (n⫽16) 33.03 (8.37) 39.75 (6.86) ⫹6.72** (3.68) 18.00 (10.99) 25.81 (11.29) ⫹7.81** (5.14)
PP (n⫽16) 35.75 (9.51) 36.75 (10.74) ⫹1.0 (3.68) 17.25 (14.29) 17.69 (13.75) ⫹0.44 (2.03)
Note: PRE indicates mean score obtained during pretesting period; POST, mean score obtained during posttest; Change,
Post⫺关(Pre1⫹Pre2兴/2). Exact P values for the Wilcoxon test comparing the change scores for the 2 groups are P⫽0.0001 for the
FM, and P⬍0.0001 for the ARA. These significant change scores are denoted by “**”.
 1296 Stroke April 2007
increases in movement as measured by the ARA. In both
cases, MP⫹PP subjects showed changes significant at the
P⫽0.0001 level. These motor changes transferred to new
ability to perform valued activities that MP⫹PP subjects had
not performed in months, such as writing, turning pages in a
book, and reaching for and drinking out of a cup.
Mental practice is thought to render its impact by at least 2
independent but interrelated mechanisms. First, stroke pa-
tients have been shown for decades to not use their more
affected arms, even when capable of doing so35,36: a phenom-
enon traditionally termed “hemiakinesia.” However, MP use
was recently shown to increase affected arm use,21 thus
overcoming this movement suppression phenomenon. In
“exit interviews” conducted with each subject participating in
the current study, all MP⫹PP subjects similarly reported
using the affected arm for valued activities of daily living
such as turning on a light, opening a refrigerator door, and
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putting on clothing items. Subjects participating in R⫹PP
showed no alterations in spontaneous use of the affected arm
for valued activities. The current study did not use objective
measures of affected arm use, such as activity monitors, to
measure arm use, but this limitation is being overcome in
current work.
The second hypothesized mental practice mechanism is
use-dependent brain reorganization, in which new cortical
areas are recruited to assist in movement of the affected arm.
Previous study results show that this phenomenon occurs
with a variety of task specific protocols, even of a brief
duration,37 including mental practice,38 and that motor
changes correlate with cortical changes. This study provides
the first randomized controlled, appropriately powered sup-
port to the hypothesis that substantive motor changes may be
produced through a regimen including mental practice. The
current study did not use neuroimaging to confirm the neural
mechanism of the treatment effect, but this limitation is being
overcome in current mental practice work. Measurement of
the duration of the MP effect is also a limitation that is being
overcome in current work.
It is commonly believed that spontaneous motor recovery
is limited to the first months after stroke. Additionally, all
subjects were reported to have “plateaued,” resulting in them
being discharged from their therapy regimens. This was
substantiated by nonsignificant changes in FM and ARA
scores between pretesting sessions 1 and 2. Given these
factors, the very rapid period during which MP subjects
exhibited motor changes, and the fact that subjects in both
groups were matched in their characteristics (including motor
scores) before intervention, motor changes exhibited by MP
subjects are unlikely to be attributable to chance.
Conclusion
Results of this trial suggest that a traditional rehabilitation
program that includes mental practice of tasks practiced
during therapy increases outcomes significantly.
Disclosures
None.
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 Mental Practice in Chronic Stroke: Results of a Randomized, Placebo-Controlled Trial
Stephen J. Page, Peter Levine and Anthony Leonard

Stroke. 2007;38:1293-1297; originally published online March 1, 2007;

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doi: 10.1161/01.STR.0000260205.67348.2b
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Copyright © 2007 American Heart Association, Inc. All rights reserved.
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